Current Events – Health

The Brookings Institution and the Organization for Economic Co-operation and Development (OECD) recently partnered to present a talk on utilizing public-private partnerships (PPPs) in order to effectively implement the United Nations’ (UN) Sustainable Development Goals (SDG). The SDGs are a list of goals, proposed by the UN, that target issues related to health, poverty, hunger, inequality, education, and climate change. According to the expert panel, partnerships connect decision-makers at the global level with the private sector, local governments, and civil society in an effort to capitalize on their specific strengths and balance their weaknesses.

Bill Gates speaking at a press conference at the end of the GAVI Alliance pledging event

For example, Gavi, The Vaccine Alliance, is a PPP that provides access to vaccines in developing countries. The major players in this alliance consist of the World Health Organization, UNICEF, The World Bank, and the Bill and Melinda Gates Foundation. Together, these organizations have successfully contributed scientific research, vaccines, and financial tools. According to Gavi, “Since its launch in 2000, [the alliance] has helped developing countries to prevent more than 7 million future deaths…Gavi support has contributed to the immunization of an additional 500 million children.” Gavi’s objectives were strategically implemented to produce results that protect developing populations and improve healthcare, which aligns with SDG 3 that aims to “ensure healthy lives and promote well-being for all at all ages.”

Partnerships are arguably the driving force behind the successful implementation of the SDGs. Governments are often slow and unreliable, while existing institutions like private corporations and civil society organizations have “on the ground” experience navigating the challenges inherent to their industry. The success of a PPP is determined by inclusivity, local implementation and ownership, transparency, accountability, political engagement, and strong focus on results. According to a study conducted by the OECD, “effective partnerships must have strong leadership, be country-led and context specific, apply the right type of action for the challenge, and maintain a clear focus on results.”

The SDGs also focus on more specific goals such as improving infrastructure, conserving oceans, and sustaining energy, which leaves room for partnerships to narrow their focus and innovate, particularly in the private sector. According to Devex, “Business leaders are still trying to understand the concept of sustainability, too, and how to integrate it into their business models.” The ODA method of developed countries donating funds to developing countries is ineffective since monetary aid does not specifically encourage the creation of new and sustainable systems. According to the Wall Street Journal, “Over the past 60 years at least $1 trillion of development-related aid has been transferred from rich countries to Africa. Yet real per-capita income today is lower than it was in the 1970s.” As is often the case, this money is lost in transit and never reaches the local level due to corrupt bureaucracies and weak relations with civil society organizations. Financial contributions from the private sector, when combined with effectual and enabling political leadership, move beyond temporary alleviation to foster a more permanent impact.

Public-private partnerships are a vital part of Goal 16, which seeks to “promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build effective, accountable and inclusive institutions at all levels.” Ultimately, PPPs allow for a more inclusive and communicative atmosphere conducive to tackling important development issues on a more direct and practical platform that enables self-sufficiency and citizen accountability. If the SDGs are to be achieved, the vital role of PPPs cannot be ignored.

According to the CDC, the U.S. fertility rate fell to another record low in 2012 with 63 births per 1,000 women. In 2007, the rate was 69.3.

During a quick scan of the shelves of one of D.C.’s remaining bookstores, journalist Jonathan V. Last’s new book entitled “What To Expect When No One’s Expecting” caught my eye. The book forecasts an impending American demographic disaster by bluntly declaring that people are having too few babies. This prompted a hasty reaction from me: “But everyone says our population is growing out of control! Aren’t 3.95 million babies named Jacob and Sophia enough!?” America’s total fertility rate, an estimation of the number of births a woman is expected to have during her lifetime based on current age-specific fertility rates, is 1.88 according to the latest figures from the CDC, a record low. This prophet of population doom argues that even this statistic is misleading because most of our fertility has been “outsourced” as we rely heavily on immigrants to prop up the fertility rate. Not including immigrants in the population profile reveals that America has a fertility rate of 1.5.

At first glance, any devout environmentalist would be thrilled with these shrinking population trends since human total environmental impact is exceeding the sustainable carrying capacity of Earth’s ecosystems. This is reflected by the I= PAT equation with I—the human impact placed upon any ecosystem—being the product of three variables: population (P), per capita level of affluence (A), and technology (T) or more accurately described as the environmental destructiveness of production techniques. It does not take a environmental economist to realize that a lower global population, and hence a lower P value, will result in less of an impact on our ecosystems.

But an interesting deaggregation of what appears to be out-of-control growth reveals cross-country disparities and cultural differences in fertility rates: Japan has a total fertility rate of 1.3 compared to Mali’s total fertility rate of 6.25. Overall, 99% of the world’s current population growth is in developing countries while the fertility rate in each of the G-8 countries is below 2.1 children per women, the rate needed for a given generation to replace itself. But environmentalists probably still significantly discount falling fertility rates. It is the absolute number that counts and even assuming that fertility levels will continue to decline, the world population is still expected to reach a staggering 9.6 billion in 2050 and 10.9 billion in 2100, according to the U.N’s medium-variant projection.

Last retorts that a shrinking population that is disproportionately old has dire economic, political, and cultural consequences. According to the U.N., “whereas the number of persons aged 60 or over is expected to more than triple by 2100, that of persons aged 80 or over is projected to increase almost seven-fold by 2100.” Last laments that a global population reduction results in a decrease of human ingenuity: “Low-fertility societies don’t innovate because their incentives for consumption tilt overwhelmingly toward health care.” Negative socio-economic externalities abound like a smaller taxpayer base and labor force and the limited availability of military-age manpower to serve in our armed forces. In 1950, there were 16 covered workers for each Social Security beneficiary. Today, there are a little less than three.

But simultaneously, what can the rationale be of the coerced low fertility rates of the Chinese? Surely the Chinese cannot be dooming themselves to a demographically poor future. And is America really subjecting itself to prolonged economic stagnation via a population implosion? A competing argument can be made that a low fertility rate can actually improve living standards. Until recently, there were few examples of developing countries with both declining fertility and rising incomes. This has changed as some countries have undergone a “Goldilocks generation” of fertility—a generation with a not too high but not too low fertility rate—with the result being fewer dependent youngsters, fewer dependent grandparents, and a bulge of working adults that increase economic output. Also, women comparatively do not have to spend more time raising children and can invest more in the education of the children that they do have and add to the productivity and quality of the labor force.

Because there are fewer dependent children and old people, households are able to save more, and there is more capital and resources that can be accumulated per capita. Economist Klaus Prettner reproduces these findings in a dynamic consumer optimization model that incorporates endogenous fertility and health investments to show that a fertility decline induces higher education and health investments that are able to compensate for declining fertility under certain circumstances. Even as absolute population levels fall, the “effective labor supply” will actually increase, proving that it’s too simplistic to reduce a country’s economic growth and productivity to a simple population numbers game.

Even as absolute population levels fall, the “effective labor supply” will actually increase, proving that it’s too simplistic to reduce a country’s economic growth and productivity to a simple population numbers game.

Consequently, questions loom about such a key determinant of our environmental and economic future. It is clear that countries concern themselves with two questions: Do we have enough people to support an ageing society? Can we take advantage of the right population numbers to spur economic growth? Viewing these questions through an environmental lens, can we find reassurance in declining fertility amidst competing claims about its effects? Are claims about the global population explosion hyperbolized? Only one thing is for certain. Motivation to stabilize population can be undermined by excessive worry that smaller numbers of young people will be supporting larger numbers of the elderly. The prevailing patterns of behavior and resource allocation can be changed in ways that reduce pensioner/worker ratios and make population stabilization more politically viable. Even if falling fertility can raise living standards—especially the living standards of poor, resource-disadvantaged people—it cannot be an excuse for inaction in the realms of smarter governance and tempered lifestyle patterns in respect to environmental crises and economic stagnation.

UPDATE: The Chinese government announced late last week that they would begin to relax its “one-child policy”. The policy was introduced in the late 1970s to combat rapid population growth but has now resulted in an increasingly aging population and extreme gender imbalance. The change will allow couples the option of having two children if just one of the parents is an only child. Previously, both parents had to be only children.

A significant number of people in the world think of China as the next leading superpower. This isn’t surprising as China boasts the second largest economy, continues to see some of the highest GDP growth rates in the world, and has more than doubled their military spending between 2005 and 2011. Despite China’s accumulation of power, they still face an issue most people in the Western world would barely even think about, access to clean water. China holds 7% of the world’s fresh water, but also 20% of the global population. Pollution, inefficiency, outdated delivery systems, and logistical problems all contribute to a growing concern that water scarcity will hit China hard in the near future.

Water Pollution in China

As China continues its rapid development, rampant pollution threatens to further deplete an already scarce resource. Thousands of industrial plants have popped up along the river banks all over China, dumping sewage and chemicals into water previously used by local populations resulting in up to 60,000 deaths per year. A 2012 report produced by the Chinese water authority indicated that “Up to 40 percent of China’s rivers were seriously polluted last year.” Three of China’s largest lakes (Tai Hu, Dian Hu, Chao Hu) are so polluted they are considered unfit for human contact. The laws fail to provide any short term economic incentive to treat water prior to discharge as the cost would be far greater than the fine imposed for environmental violations.

In addition to the extensive pollution of water by industries, there exists a regional disparity in water availability, especially when compared against population concentrations. Northern China only holds 23% of total water resources while supporting 40% of the total population as well as 64% of China’s arable land. 8 out of the 11 “dry” provinces, indicating water poverty at a per capita water consumption under 1,000m³, are located in the north as well as all 6 “deficit” provinces, which consume more water than they actually have. 4 out of these 6 provinces are home to China’s most populated cities including Shanghai and Beijing. In an attempt to bring water from the south to the north the Chinese Government has begun one of the largest engineering projects ever conceived. The South-North Water Diversion Project will link the Yellow and Yangzi rivers via thee new channels at a cost of almost $80 billion. While this would be an amazing feat of modern engineering, the environmental cost could be devastating. Major dam projects proposed on the Mekong and Brahmaputra rivers could also lead to sour relations and pollution issues with their downstream neighbors.

China does not necessarily need to go to such lengths to increase the supply of water, but rather reduce the demand. Currently, China’s water productivity is significantly lower than other competitive economies in Europe. The Economist writes, “For each cubic metre of water used, China gets $8-worth of output. The average for European countries is $58 per cubic metre. Of course, these countries are richer—but they are not seven times richer.” The price of water in China is extremely undervalued despite its obvious scarcity, causing it to be used carelessly by businesses and people alike. The low cost of water renders various forms of treatment, desalination, and recycling economically nonviable. Industries in China only recycle about 40% of their water while dumping the rest in various rivers and lakes. The Government is attempting to implement a complex pricing scheme to punish over use while retaining lower prices for rural farmers and areas with higher water efficiency. While solutions around efficiency seem cheaper and more effective, there are evident problems that may arise. Increases in the cost of water can affect poorer people who are already struggling to pay, or cut into the livelihood of rural farming areas in the north. An increase in the price of water can reduce the productivity of various industries that use it for cooling machinery or cleaning products. The largest industrial user of water is the energy sector where roughly 97% of China’s energy supply is dependent on water. Increases in price or water scarcity can have huge effects on the sectors production capacity and price.

Water Deficits by Province

Water scarcity in China is a complex issue that can’t be fixed with giant engineering programs alone. Time is running out as over half of China’s larger rivers have disappeared in the last 60 years. Hopefully additional support to environmental regulation agencies and stricter penalties for violations will push industries to recycle and treat more of their water supply. In addition advancements in agriculture practices in rural areas may help lower the amount water necessary for use. China could also be more wary of building huge cities in regions without easy access to water saving time and money on large diversion projects. Ideally, focusing on issues of efficiency and conservation may be best suited to address China’s water crisis and ensure their continued economic expansion.

October 2013 marked the 3rd anniversary of the widely-documented 2010 cholera outbreak in Haiti, a small developing Caribbean country which shares the island of Hispaniola with the Dominican Republic. Haiti first reported cases of cholera in October 2010; within one month cholera had spread to all parts of Haiti and the Dominican Republic. “Between October 2010 and August 2013, more than 670,000 people in Haiti were treated for cholera, with around 8,200 deaths attributed to the outbreak.”

Cholera is an intestinal infection, caused by ingestion – usually in contaminated food or water – of the bacterium Vibrio cholerae. Cholera causes diarrhea and vomiting, symptoms that can lead to dehydration and death within hours. Every year, 3-5 million people develop symptoms and 100,000-200,000 people die due to cholera worldwide. Many developed countries, like the United States and Canada, have largely eliminated domestic cholera. However, global cholera incidence has increased since 2005; in 2011, more than 60% of reported cases occurred in the Americas- mostly in Haiti.

As with many other diseases, cholera usually affects vulnerable populations. Those with low immunity are most likely to develop symptoms if exposed, and cholera can spread easily in areas with poor infrastructure and sanitation facilities. While cholera has been largely eradicated in most of the developed world, “cholera remains a global threat to public health and a key indicator of lack of social development. Recently, the re-emergence of cholera has been noted in parallel with the ever-increasing size of vulnerable populations living in unsanitary conditions.”

While many other countries in the Americas dealt with cholera epidemics in recent decades, Haiti had not encountered cholera for 100 years when the 2010 outbreak began. This meant that there was no natural immunity or protection within the Haitian population against this bacterium, which spread quickly. The cholera epidemic also began a mere 9 months after a magnitude 7.0 earthquake hit Haiti, which had destroyed infrastructure and displaced 1.5 million people. 80% of cases can usually be successfully treated with oral rehydration salts, but cholera in Haiti has had a high fatality rate- partially because of limited access to health services.

Three years after the epidemic began, the emergency response is slowly winding down. However, the underlying problems that allowed cholera to spread so quickly – most notably lack of access to clean water, sanitation facilities, and health services – remain unsolved. Haiti has the lowest coverage of improved water and sanitation services in the Western Hemisphere. According to the World Health Organization, in 2010 only 64% of Haitians had access to clean drinking water and only 26% had access to adequate sanitation facilities– and the number of people in Haiti with access to adequate sanitation has since decreased to 17%. But the problems extend beyond merely providing access; one recent survey showed that 50% of improved water sources in rural Haitian households tested positive for e. coli. To meet the Millenium Development Goal of halving the proportion of the world’s population without access to improved water and sanitation facilities by 2015, Haiti would need to achieve 74% and 63% coverage for improved water and sanitation facilities, respectively. Unless the situation quickly improves, these goals likely will not be met.

These unsolved problems in Haiti could represent an international health threat as well. In the years since the beginning of the epidemic in Haiti, cholera has spread to Cuba, most likely through international travel. Health officials in Mexico detected cases of cholera in early September 2013; since then, there have been 171 reported cases in Mexico. 75% of individuals infected with the bacteria do not show symptoms- but can still infect others around them. If cholera remains present in Haiti at current levels, many other countries are then at risk of ‘imported’ cases.

In February 2013, the Haitian government began a National Plan to eliminate endemic cholera in 10 years through improvements in water and sanitation, health care services, epidemiology and surveillance, and health and hygiene promotion. It is estimated that the National Plan will need $2.2 billion to be successful; however, funds and resources are scarce. A recent publication by the Center for Strategic and International Studies, Water and Sanitation in the Time of Cholera: Sustaining Progress on Water, Sanitation, and Health in Haiti, argues that the international community – specifically the United States – must step in and contribute to support these anti-cholera efforts. Improvements in water and sanitation coverage and health care in Haiti could have far reaching effects, such as decreasing the disease burden from other diarrheal and water-born illnesses. The report argues: “failing to adequately support Haiti’s water and sanitation activities threatens the sustainability of other U.S. development investments in the country, including improved population health, economic development, the empowerment of women, and progress toward democratic governance and political participation.”

Cholera is preventable with adequate water, sanitation, and healthcare services and treatable with oral rehydration salts; the most effective anti-cholera campaign in Haiti will combine all these strategies. Three years after the epidemic began, international coverage, attention, and action are beginning to wind down. However, these challenges persist and need permanent solutions to prevent future cases, future unnecessary deaths, and possible future epidemics in other countries. Eliminating cholera in Haiti will require a sustainable and coordinated long-term strategy – and will require participation from a variety of actors, including domestic governments and communities, non-profits, and the international community.

Brazil recently announced plans to create a low-cost measles and rubella vaccine, specifically for export to developing countries. The Oswaldo Cruz Foundation, Brazil’s top medical research facility, is partnering with the Bill & Melinda Gates Foundation to create, produce, and export the vaccine.

Measles and rubella, viruses that primarily affect children, have been eradicated in most developed countries. Brazil, for example, eradicated measles in 2000 and rubella in 2009. These highly contagious viruses spread through human contact (sneezing and coughing) and no anti-viral cure exists for either disease, so prevention through vaccination is essential. In 1980, measles alone caused 2.6 million deaths each year. However, the development of effective vaccines and widespread vaccination campaigns has greatly reduced the prevalence of these diseases around the world. Between 2000 and 2011, there was a 71% decrease in measles cases globally due to effective vaccination. But measles still kills 158,000 people every year, mostly children in low-income countries.

Bio-Manguinhos, the unit of the Oswaldo Cruz Foundation that will produce the new vaccine, already produces an effective combination vaccine for measles, mumps, and rubella. However, many developing countries cannot afford the existing vaccine because of its high cost. For example, Pakistan experienced a measles epidemic earlier this year- there were 239 measles-related deaths in the country from January to April 2013. Dr. Tanvir Ahmed, the Director-General of Health Services for Punjab province, attributes the recent outbreak to low vaccination coverage: “In the districts there are even pockets where there is no vaccination coverage. The average for Punjab is 58%.”

Brazil hopes to produce 30 million doses of the new vaccine per year by 2017. This measles and rubella vaccine will be the only produced by Brazil solely for export and will cost $0.54 per dose. Right now, India produces only similar vaccines for developing countries.

This new development in global health showcases the solutions cross-sector, international partnerships can produce. The Oswaldo Cruz Foundation in Brazil received a $1 million grant from the Gates Foundation; in addition, the Brazilian Health Ministry has pledged $727 million to construct a new pharmaceutical plant to facilitate production. The new vaccine will be sold to low-income, developing countries, primarily in Africa, Asia, and Latin America. The international community has committed to improving child health around the world; the 4th Millenium Development Goal aims to reduce the 1990 under-5 mortality rate by two-third by 2015 and the World Health Assembly committed in 2010 to reducing deaths from measles (2000 levels) by 95% by 2015. This new vaccine will, hopefully, help us to meet these goals through cost-effective strategies, like vaccinations.

Rabies is a terrifying disease that kills approximately 60,000 people worldwide each year. Though scientific innovation has created vaccines that are effective before and after exposure to the virus, there is no way to cure rabies once symptoms have begun. Rabies is a zoonosis, meaning that it is transmitted from animals to humans. Rabies is a threat in about 150 countries, but its fatalities are constrained to the developing world with 95% of rabies cases occur in Asia and Africa. Over 99% of deaths from rabies occur in developing countries, one-third in China and India alone.

Risk of human rabies, 2011 (WHO)

Rabies is a neglected disease and most commonly affects poor, young, and vulnerable populations. Children are particularly at risk– 40% of those bitten by a suspected rabid animal are under 15 – and the risk is highest in rural areas, where required vaccines may not be readily available. While rabies is always present in the wild, most human cases are caused by dog bites. Canine rabies threatens more than 3 billion people in Asia and Africa.

While many perceive polio as a largely eradicated disease of the past, a recent resurgence of new cases in politically unstable regions of the world has brought the disease back into the news. Polio is devastating and highly infectious: it affects the nervous system and can cause irreversible paralysis and death, primarily in young children. While there is still no cure for polio, five vaccines are able to prevent transmission of the polio virus. Global immunization and other strategies have decreased cases by 99% in approximately two decades. However, since most people infected with polio do not show symptoms, the World Health Organization (WHO) treats any confirmed case as a potential epidemic. Although evidence has shown that polio eradication is possible through widespread immunization, the disease is still endemic in three countries (Afghanistan, Nigeria, and Pakistan) and tackling the last 1% of polio cases around the world has proved a challenging task.

Child receives polio vaccine

All countries currently remain at risk for ‘imported’ cases of polio, particularly states bordering endemic areas or when political instability or other factors inhibits necessary immunizations. So far in 2013, there have been 192 reported cases of polio worldwide. Of those reported cases, 108 were in Somalia, a non-endemic war-torn country whose political instability and violence has made providing necessary medical services, like immunizations, dangerous and difficult.

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